ABSTRACT

Context.— Concerns about the working and learning environment of residency training
continue to surface. Previous surveys of residents have focused on work hours
and income, but have shed little light on how residents view their training
experience.

Objective.— To provide a description of the internship year as seen by a large cross
section of second-year residents.

Design.— Mail survey conducted in 1991.

Setting.— Residency programs in the United States.

Participants.— Random 10% sample (N=1773) of all second-year residents listed in the
American Medical Association's medical research and information database.

Main Outcome Measures.— What and who contributes most to residents' learning during internships,
degree of satisfaction with the internship experience, on-call and sleep schedules,
incidents of perceived mistreatment or abuse, observations of unethical behavior,
and experiences of harassment or discrimination.

Results.— A total of 1277 surveys (72%) of 1773 mailed were returned. Overall,
respondents reported a moderate level of satisfaction with their first year
of residency. On a scale of 0 to 3, residents rated other residents as contributing
most (score of 2.3) to their learning, with special patients ranked second
(2.1). During a typical work week, residents reported that they spent an average
of 56.9 hours on call in the hospital. A total of 1185 (93%) residents reported
experiencing at least 1 incident of perceived mistreatment, with 53% reporting
being belittled or humiliated by more senior residents. Among women residents,
63% reported having experienced at least 1 episode of sexual harassment or
discrimination. A total of 45% of residents reported having observed another
individual falsifying medical records, and 70% saw a colleague working in
an impaired condition, most often lack of sleep. Regression analyses suggest
that satisfaction with the residency experience was associated with the presence
of factors that enhanced learning, and fewer experiences of perceived mistreatment.

Conclusions.— Residents report significant problems during their internship experience.
Satisfaction with internship is enhanced by positive learning experiences
and lack of mistreatment.

Figures in this Article

IN SPITE OF recent recommendations and changes, resident working conditions
continue to be a source of concern for both residents and hospital administrators.
Of all the stages of medical training, the first year of residency is perhaps
the most stressful.1 More than medical school,
more than the later years of residency, the first postgraduate year is experienced
as a trial by fire.2 To be successful, interns
must learn to balance such diverse demands as the responsibility for patient
care, economic hardships, on-call schedules, patient death, the need for constant
learning, the task of teaching, the requirements of attending physicians and
senior residents, along with the necessities of family and personal life.

Two earlier national surveys cited by Silberger et al,3
although limited by their low response rates (<45%), found a trend toward
rising dissatisfaction among residents, with the number of problem areas cited
by residents increasing from 1983 to 1987. Schwartz et al4
report that the 5 factors that have the most negative effects on residents
are (1) lack of sleep, (2) frequent night calls, (3) uncompromising attending
physicians, (4) large patient loads, and (5) too much "scut" work.

An early study by Asken and Raham5 found
that sleep deprivation among residents had potentially severe negative consequences
on patient care. More recently, a literature review by Samkoff and Jacques6 concluded that although sleep-deprived residents can
compensate for sleep loss during crises, they are more prone to error on routine
repetitive tasks. Any activity that requires sustained vigilance shows deficits
in the face of sleep loss. Previous work by the present authors has shown
that residents believe that sleep deprivation impairs their capacity to care
for patients and causes them to have more conflicts with the professional
staff.7

Within the time frame provided by long work hours, interns must learn
both the clinical skills of their profession and the implicit messages about
professional attitudes and behaviors. One clue to these implicit messages
is to be found by looking at trainees' accounts of how they are treated and
their perceptions of their working conditions.8
Such qualities of the learning environment, including reports of perceived
sexual harassment, discrimination, mistreatment, and unethical or unprofessional
behavior on the part of colleagues and supervisors, have been documented over
the past decade at the undergraduate level.9- 12
In 1991, Baldwin et al11 reported that 96% of
581 senior medical students at 10 widely scattered schools reported having
experienced at least 1 episode of perceived mistreatment, usually at the hands
of their supervisors and teachers. In addition, 69% of the women and 25% of
the men in the study reported at least 1 personal experience of sexual harassment
during undergraduate medical training.11 Komaromy
et al13 found that 73% of women and 22% of men
in 1 specialty reported that they were sexually harassed at least once during
their medical training.13 A more recently published
study, conducted as a follow-up of 571 medical students from 10 medical schools
when they were in their residency, reported that 68.4% of the women and 14.2%
of the men had experienced sexual harassment or discrimination at some point
during their internship year.14

How do these experiences affect residents' perceptions of their learning
environment and their perceived satisfaction with their internship year? In
retrospect, most physicians recall their internship year as a valuable and
exciting time, a defining experience in their quest for professional competence
and identity.2 The source of these positive
reactions appears to hinge on the enormous gain in knowledge and skills, as
well as the relationships residents are able to develop with colleagues and
attending faculty. In an examination of first-year residency stress, Badger
et al15 found strong positive correlations between
the mood of residents and their perceptions of the faculty's commitment to
teaching, availability, and sensitivity to their problems. An interested,
accessible faculty represents a reward for a resident's effort, as well as
an antidote to the pressures of the internship year.

Unfortunately, the pressures felt by residents are usually underestimated
by other members of the medical community. Urbach et al16
concluded that members of the medical hierarchy are likely to minimize the
prevalence of serious house-staff distress, and that the degree to which the
prevalence is underestimated increases as one moves up the hierarchy.

These reports are suggestive, even provocative, but provide no broad
portrait of how residents actually perceive their internship year. Continuing
the series of surveys assessing residency hours and working conditions conducted
by the American Medical Association in 1983 and 1987,3
the current study was undertaken to provide a description of the internship
or first-year residency experience from the viewpoint of residents who had
just completed their first postgraduate year. What and who do residents say
contributes most to their learning? What accounts for their overall satisfaction
with their experience? How much mistreatment and sexual harassment do residents
report? What recommendations can be made to enhance the residency experience?

METHODS

Survey Instrument

The survey instrument used in this study was based on an earlier questionnaire
examining medical student's perceptions of their educational experience.11 Some of the previous questions were used, others were
revised, and new ones were added, resulting in a 13-page questionnaire. Along
with basic demographic information, second-year residents were asked to think
about their just completed internship year and to answer questions concerning
their general satisfaction with their internship experience, on-call and sleep
schedules, incidents of perceived mistreatment or abuse, observations of unethical
behavior on the part of others, and experiences with harassment or discrimination.

Based on previous work, incidents of perceived mistreatment included
being publicly belittled or humiliated, experiencing sexual and racial harassment
or discrimination, being assigned tasks for punishment rather than for learning,
receiving threats to one's career, and physical abuse.11
Incidents of observed unethical conduct included falsification of patient
records, mistreatment of patients, observing others working in an impaired
condition, and having others take credit for one's own work. Respondents were
asked to indicate their answers using the following 4-point scale: 0 indicates
never; 1, rarely (1-2 times); 2, sometimes (3-4 times); and 4, often (5 or
more times). Residents were also asked to identify the source of the reported
mistreatment or unethical conduct: medical students, residents at the same
level, residents at a higher level, attending faculty, nurses, or patients.
At the end of the survey, residents could write comments and more detailed
descriptions of any incidents or events.

Sample

A simple, random, 10% sample (N=1773) of all second-year residents was
drawn from the American Medical Association's medical research and information
database and asked to comment on their internship year. The population from
which this sample was drawn included all second-year residents from every
residency program in the United States that answered the 1990 Survey of Graduate
Medical Education programs. Responses to this survey were received from 83%
of residency programs.17

After pilot testing and revision, the final questionnaire was mailed
in January 1991 to all residents selected for the sample, along with a letter
of explanation, a return envelope, and a postcard with the resident's name
and address typed on it. The month of January was selected to begin the survey
because it was the earliest that the names of residents could be obtained
from the medical research and information database. Responses to this survey
were anonymous. Residents were asked to return the postcard and the envelope
containing the completed questionnaire separately. This enabled the investigators
to identify those subjects who had responded to the questionnaire, while maintaining
their anonymity. Residents were also instructed to return the postcard if
they declined to participate. All members of the sample who did not return
the postcard were mailed a follow-up survey package on 2 subsequent occasions.
As a final step, efforts were made to contact nonresponding residents by telephone.

The resulting data were analyzed using standard statistical packages
to derive general frequencies and cross-tabulations. Correlates of overall
satisfaction with residency experience were defined by using Pearson correlations
and stepwise regression techniques.

RESULTS

Response Rate

The final number of surveys returned was 1277, a 72% response rate,
of which 1274 contained complete information. With the exception of a modest
overreporting of graduates from United States Liaison Committee on Medical
Education (US-LCME) accredited medical schools and nonminority residents,
the sample demonstrated a close approximation of the specialty distribution
for that year.17

How Do Residents Say They Learn?

Residents were asked to rate the degree to which a number of factors
contributed to their learning experience using a 4-point scale (0 [not at
all] to 3 [a great deal]). Residents reported (Figure 1) that the highest contribution to their learning came from
other residents (2.3), with special patients ranked second (2.1). Attending
physicians, patient rounds, and reading were all tied at about 2.0. Medical
students (0.9) and educational leave (0.5) were rated lower.

Second-year residents' ratings of what contributed to their learning
during an internship year.

Time spent with attending physicians averaged about 2.49 hours a day,
but showed wide variations within the sample (SD, 2.3 hours). Approximately
30% of the respondents reported spending 1 hour or less per day with an attending
physician, while 19% claimed 3 or more hours. Men and women reported about
the same amount of time each day with attending physicians (2.5 vs 2.4 hours,
respectively). Time with attending physicians per day varied by specialty
(P<.001), with residents in surgery (3.1 hours),
family practice (3.0 hours), and hospital support specialties, which include
the departments of radiology, pathology, and physical rehabilitation (3.0
hours), reporting the most time, while transitional-year residents (2.3 hours)
and residents in psychiatry (1.9 hours) averaged the least.

Satisfaction With the First Year of Residency

Overall, respondents reported a moderate level of satisfaction with
their first year of residency, with an average rating of 4.56 (good) on a
scale of 1 (poor) to 7 (excellent) (SD, 1.28). Approximately 24% of the respondents
reported ratings of 5 or above, while just under 20% noted ratings of 3 or
below. Looking at satisfaction with specific aspects of the internship year,
residents seem most satisfied with what they learned (4.8) and their relationships
within the hospital (4.8). Residents' relationships with their own friends
and family outside of the hospital (3.9) and personnel support services (3.6)
were rated as the least satisfying aspects of the experience. Once again,
there was substantial variation across the sample. Residents in the 3 primary
care specialties expressed the most overall satisfaction with their first
postgraduate year experience (4.6-4.7), while those in psychiatry were least
satisfied (4.2) (one-way analysis of variance, P<.01).
Men reported significantly more overall satisfaction (4.6) than did women
(4.4) (Student t test, P<.001).
Gender differences were most pronounced in family practice and surgery.

Sleep Deprivation

Asked how frequently they had experienced sleep deprivation during their
first year, residents gave a modal response of 3 on a scale of 0 (never) to
4 (almost daily). Over 10% indicated that sleep deprivation was an almost
daily occurrence. Residents reported an average of 37.6 hours (SD, 9.88) as
the largest number of hours without sleep during their first postgraduate
year. During a typical work week, residents reported that they spent an average
of 56.9 hours on call in the hospital, although here again there were wide
variations in response (SD, 30.19). Roughly 25% of the residents reported
being on call in the hospital over 80 hours per week, while an equal number
were on call less than 35 hours per week. Only 15.2% of the sample claimed
to have been on call outside of the hospital. As expected, residents in surgery
reported the highest average hours on call (72.5 hours), while psychiatry
(37.3 hours) and hospital support specialties (36.2 hours) residents reported
the lowest (one-way analysis of variance, P<.001).

Types of Perceived Mistreatment

Overall, 1185 residents, or 93% of the sample, reported at least 1 experience
of perceived mistreatment during the internship year (Table 1). Of the specific types reported, the highest percentage
was recorded for public humiliation or belittlement. Residents also indicated
that this was the most distressing type of mistreatment. Physical abuse—being
slapped, pushed, kicked, or hit—was less prevalent and occurred mostly
at the hands of patients. Sources of perceived mistreatment correspond to
the medical hierarchy, with attending faculty and residents at a higher level
cited most often, followed by nurses and patients.

While simplifying data presentation, overall statistics stated in terms
of "at least once" give little indication of the frequency of these experiences
and can be misleading if mistreatment is reported as a single-time event.
To provide a more conservative metric, the third column of Table 1 presents the percentage of the respondents indicating that
they experienced each type of mistreatment on more than 3 occasions (a combination
of the sometimes and often response categories). Using this criterion, 53%
of respondents reported that they were belittled or humiliated by more senior
residents, while just over 21% reported someone taking credit for their work.
Being given "tasks for punishment," "being slapped, pushed, kicked or hit,"
and having someone "threatening your reputation or career" were reported as
a more frequent occurrence by over 10% of the responding residents.

Observations of Unprofessional and Unethical Conduct

Over 45% of the respondents reported having personally observed other
persons falsifying medical records on at least 1 occasion, with just under
20% characterizing this as more than a rare event. Nurses, followed by fellow
residents, were cited most frequently as engaging in this falsification.

Almost three quarters of all respondents reported having observed what
they considered to be mistreatment of patients by other residents, attending
faculty, and nurses on at least 1 occasion, with almost 40% characterizing
this as a more frequent event. Here again, nurses were the group most often
cited, with over 30% of residents saying they had seen this behavior on more
than 1 occasion. Marginal comments by respondents, some quite lengthy, described
examples of this type of mistreatment ranging from not fully informing a patient
prior to a procedure, to using comatose patients to demonstrate deep-pain
reflexes to students.

Overall, 70% of the residents reported having personally observed a
colleague working in an impaired condition. Most often these colleagues were
other residents at either the same or at a higher level. Over 14% of respondents
said that this happened often (5 or more times). Lack of sleep (56.9%) was
by far the most prominent cause for observations of impaired behavior among
others, followed by working too hurriedly (40.1%), incompetence (37.0%), and
emotional problems (36.8%). Alcohol use as a reason for impairment was reported
by less than 15% of respondents, while prescription drug abuse and illegal
drug use were cited by only 5.0%.

Sexual Harassment

Overall, 30% of the residents reported having experienced at least 1
episode that they considered to be sexual harassment or discrimination during
their first year of training (Table 1).
Women (63.0%) claimed to have experienced such events significantly more frequently
than did men (15.3%) (Student t test, P<.001). For women residents, the most frequent sources of such
behavior included attending faculty, patients, and residents at a higher level,
in that order. Nurses, patients, and faculty were more frequently implicated
by reporting men. For women, such harassment or discrimination was most commonly
reported as sexual slurs or comments (35.8%), followed by favoritism (23.7%),
sexual advances (16.4%), denied opportunities (15.9%), and poor evaluations
(13.1%). The exchange of rewards for sexual favors was rare (1.5%). For women,
reports of sexual harassment or discrimination also varied by specialty, with
the highest prevalence being reported in the transitional year (81.5%) and
in the specialty of surgery (80.7%). The lowest percentages were recorded
for the hospital support specialties (58.3%) and pediatrics (47.8%).

Correlates of Satisfaction With the First Year of Residency

Pearson correlation coefficients comparing overall satisfaction with
the first-year residency experience reveal statistically significant positive
relationships (P<.001) with the degree to which
attending physicians (+.46), patient rounds (+.25), lectures (+.27), and seminars
(+.27) contributed to the interns' learning. Note that, although residents
say that they learn the most from their peers (Figure 1), it is contact with the attending physicians that is most
predictive of satisfaction. Statistically significant negative relationships
(P<.001) were found between levels of reported
mistreatment and satisfaction ratings, age of respondent (−.15, older
residents were less satisfied), and frequency of sleep deprivation (−.20).
The strongest negative correlations were found with reports of being belittled
or humiliated (−.30), being assigned tasks for punishment (−.29),
and threats to the resident's career (−.27).

To assess the joint impact of these factors, all were entered into a
stepwise regression analysis designed to maximize prediction of overall satisfaction
ratings. The resulting model, including only those factors significant at
the .01 level, has an R2 of .36 and is
displayed in Table 2. This model
includes 11 separate variables. Setting aside the tendency for older residents
to report less satisfaction, the remaining 10 variables can be grouped into
2 clusters: positive factors of the residency experience that are seen as
enhancing learning (attending physician, patient rounds, seminars, other residents,
and medical students) and negative factors (experiences of belittlement and
humiliation, threats to the resident's career, being assigned tasks for punishment,
and frequency of sleep deprivation). Respondents who reported having had more
assistance in learning and fewer instances of mistreatment at the residency
site report more overall satisfaction with their residency experience.

An examination of a plot of the residuals from this model against overall
satisfaction rating shows no obvious outliers and no indication of heteroscedasticity,
implying that the derived model predicts equally well across all levels of
satisfaction. A comparison of residuals across medical specialties suggests
that the model is most effective in predicting satisfaction for internal medicine,
family practice, and the hospital support specialties, and is least effective
in predicting satisfaction for residents in psychiatry.

COMMENT

The data reported here constitute the first national sampling of residents'
self-reports of their experiences during, and satisfaction with, their internship
year. Overall, they reveal a moderate level of satisfaction with their learning
and work experience, but with substantial variation across both individuals
and specialties. Nearly 20% of respondents rated their experiences as less
than satisfactory. Almost all of the first postgraduate year residents reported
that they personally had experienced at least 1 incident of mistreatment or
sexual harassment, most commonly verbal attacks, and mainly from those in
positions of authority. They also reported a substantial number of personal
observations of falsification of medical records, mistreatment of patients,
others taking credit for their work, and colleagues working in an impaired
condition. Statistical analyses suggest that overall satisfaction with the
internship year is the result of the degree to which sources of learning are
available and perceived mistreatment is minimized. Supporting the validity
of these findings is the large size and distribution of the sample, as well
as the relatively high response rate from this busy group of subjects.

These data have their limitations. First, residents' responses are self-reports,
not controlled observations of behavior. The self-serving biases of this type
of retrospective report are well known. The high rates of perceived mistreatment
reported by this sample may suggest that rather than reporting on mistreatment
as such, residents were using the questionnaire to express grievances far
beyond the intended scope of the questions asked. Viewed in this manner, these
data are not an indication of how residents are treated, but are more of a
gauge of residents' general level of satisfaction or dissatisfaction with
their experience.

On the other hand, the responses on this survey do represent the residents'
perceptions and, as such, constitute their experiences. To quote Thomas and
Znaniecki,18 "That which we believe to be real
is real in its consequences." Whether mistreatment is actual or merely perceived,
the relatively high level of reported negative experiences is significant
in and of itself. We take these perceptions as reported by our resident respondents
as real. The reasons for these reported perceptions are beyond the scope of
this type of cross-sectional survey. Other than personal interviews, it is
difficult to conceive of any other method of securing residents' responses,
especially from such a large sample.

Second, some time has passed since these data were collected. However,
although the past few years have seen increased discussion regarding resident
working conditions, little published evidence exists to show that the residency
experience in the United States has substantially changed. Certainly, residents
continue to voice their concerns about working conditions within their professional
organizations. In addition, 2 Canadian studies, reporting data collected in
1993 and 1994, found that residents reported experiences of discrimination
and abuse at rates similar to those in our data.19,20
If the experience of residents in Canada is any parallel, the issues we report
here continue to be a part of residents' perceptions.

The findings of this study bear a remarkable similarity to the results
reported in our earlier study of perceived mistreatment among medical students.11 With the exception of lower overall reports of sexual
harassment, most of the figures are within 1 or 2 percentage points of those
reported by senior medical students. We find this level of consistency remarkable.
Clearly, medical students do not come to perceive their environment as more
benign with the transition into residency. Since the residents in the sample
came from many different programs in many parts of the country, the levels
of reported mistreatment and sexual harassment appear to be a relative constant.
The perception that some level of mistreatment is a part of residency training
is widespread and must be regarded as the norm rather than the exception.

The first year of residency is a time for learning as well as service,
and respondents report that a wide variety of factors, both formal and informal,
contribute to their learning experience. Although time with attending physicians
and formal instruction constitute the basic institutional structure of their
ongoing training, residents perceive that much of what they learn during their
internship comes from their peers and special patients rather than in more
formal instructional settings.

The reports of experiences of sexual harassment and discrimination expand
our picture of these behaviors, corroborating the more limited studies of
the past.9- 14
A sizable proportion of female residents, and even some male residents, report
experiences of harassment and mistreatment tied to their gender. Most of this
is linked to verbally expressed attitudes of others and appears to fall short
of what is legally actionable. Still, the elevated prevalence of such behaviors
at a time when women constitute an ever increasing proportion of physicians
is cause for concern.

The surprisingly high figures of observations of colleagues engaging
in questionable ethical or professional behavior or working in impaired conditions
highlights an added layer of tension faced by new residents. The level of
misconduct, reported by participants who are in the best position to know,
is disturbing. We hasten to add that the data do not say that all or even
most hospital personnel engage in the types of conduct cited. On the other
hand, they are pervasive enough within the experience of the residents in
this survey to merit closer scrutiny.

The reports of these residents suggest that current efforts to combat
physician impairment may be misplaced in emphasis. While the predominant view,
and most intervention programs, hold that substance abuse is the major culprit,
these data strongly suggest that sleep deprivation, working too hurriedly,
emotional problems, and incompetence account for the bulk of the incidents
cited. The silver lining here is that all 4 of these reasons are potentially
remediable.

While this survey allows for generalizations about residency experiences
across the country, it also highlights the wide variability in those experiences.
Consistent with the literature, surgery and obstetrics/gynecology consistently
demanded the most time and effort from their residents, as well as reporting
the highest levels of sexual harassment, discrimination, and other types of
perceived mistreatment. To balance this, however, time with attending physicians
was among the highest for surgery and obstetrics/gynecology when compared
with the other medical specialties. Alongside differences across specialties,
it is also important to note that even within specialties there is considerable
variation. What is true for any 1 residency program cannot be said to be true
for all.

Using data from all specialties, our analyses examining factors that
predict satisfaction with the first year of residency suggest that satisfaction
is, at least in part, the result of a simple ratio: maximizing learning while
minimizing perceived mistreatment. Anything that enhances residents' sense
of learning magnifies the positive benefits of their situation.21
At the same time, anything that decreases a sense of being mistreated will
lessen the felt burden of the experience. Satisfaction with residency is the
result of the ratio between positive learning and negative work experiences:
a reward-punishment ratio. If the learning is high enough, residents are willing
to tolerate a certain amount of discomfort, whether stemming from the educational
environment in general or from specific individuals within it.22
However, if the level of discomfort is too high or the amount learned declines,
frustration rises and satisfaction wanes.

Our data indicate that some medical specialties demand more time and
effort and appear on the surface to provide less emotionally supportive environments.
Yet, in spite of these apparent deprivations, reported satisfaction is not
notably lower when compared with other specialties. The notion of a trade-off
between learning and perceptions of mistreatment helps to explain this seeming
paradox. If residents feel mistreated during their contact with their superiors,
but feel that they learn from this contact, they may well discount the short-term
negatives of the experience and focus on the long-term benefits of the education
they receive. We suspect, but have no data to support, that for some specialties,
increased time with attending physicians and the opportunity to learn from
resident colleagues and special patients offsets the greater demands of training
in these specialties. Although the residents in this survey reported learning
the most from their fellow residents, it is possible that they may value the
education they receive from attending physicians more.21,22
New Medicare regulations governing billing practices in the clinical teaching
environment may serve indirectly to increase the amount of contact time between
residents and attending physicians and thereby increase overall resident satisfaction.

This is not to suggest that residents' feelings of being mistreated
should simply be ignored. Satisfaction can be enhanced by either a perceived
increase in learning or a reduction in perceived mistreatment of all types.
Residency directors who wish to improve the felt satisfaction among the resident
population should consider a 2-pronged approach. First, they should strive
to increase the learning opportunities for residents. This can be accomplished
by a combination of things: increasing the accessibility of residents to attending
faculty, facilitating contacts among residents, or providing time for independent
reading. Second, residency directors must make clear the standards of conduct
for all professional personnel and intervene when conduct falls short of these
standards. Although the discomforts of residency cannot be eliminated, a conscious
effort at reducing the intern's sense of being mistreated should enhance residents'
satisfactions.

Despite the discomforts noted here and in the literature, the first
year of graduate medical education appears to provide a moderately satisfying
learning and working experience for the large majority of residents. In this
sense, the data confirm the memory of most physicians. The residency training
experience does consistently produce physicians with a high level of professional
commitment who provide quality patient care in spite of the pressures and
stresses.22 The system works for the most part,
but it is a system that exhibits some signs of strain. Of particular concern
is what will happen to the role of the attending faculty in the future. Faced
with the increasing burdens of accountability that come with medical service
plans and managed care capitation arrangements, attending physicians may well
have less, not more time for their teaching function over the coming years.
If this time diminishes too far, residents are likely to feel deprived of
learning—the greatest reward of the training years. In this context
we fear that feeling of mistreatment may rise and satisfaction will suffer.

This research has described in detail for the first time the experience
of abuse (we prefer the term perceived mistreatment)
in residents in the United States, and has demonstrated its close similarity
to the pattern widely experienced by medical students. The ratio between this
perceived mistreatment and the education acquired by residents is the crucial
underpinning to residents' satisfaction. It is our hope that these findings
will encourage residency review committees and individual program directors
to take steps to meet the concerns expressed and to improve the learning and
working environment of residents.

Letters

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